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Ramadan KT, McFadden C, Gomes B, Schwiegelshohn F, Ribeiro RVP, Chan HHL, Betz V, Cypel M, Lilge L. Determination of Optical Properties and Photodynamic Threshold of Lung Tissue for Treatment Planning of In Vivo Lung Perfusion Assisted Photodynamic Therapy. Photodiagnosis Photodyn Ther 2021; 35:102353. [PMID: 34048969 DOI: 10.1016/j.pdpdt.2021.102353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Isolated lung metastases in sarcoma and colorectal cancer patients are inadequately treated with current standard therapies. In Vivo Lung Perfusion, a novel platform, could overcome limitations to photodynamic therapy treatment volumes by using low cellular perfusate, removing blood, theoretically allowing greater light penetration. To develop personalized photodynamic therapy protocols requires in silico light propagation simulations based on optical properties and maximal permissible photodynamic threshold dose of lung tissue. This study presents quantification of optical properties for two perfusates and the photodynamic threshold for 5-ALA and Chlorin e6. METHODS Porcine and human lungs were placed on Ex Vivo Lung Perfusion, and perfused with acellular solution or blood. Isotropic diffusers were placed within bronchi and on lung surface for light transmission measurements, from which absorption and light scattering properties were calculated at multiple wavelengths. Separately, pigs were injected with 5-ALA or Chlorin e6, and lung tissue was irradiated at increasing doses. Resultant lesion sizes were measured by CT and histology to quantify the photodynamic threshold. RESULTS Low cellular perfusate reduced the tissue absorption coefficient significantly, increasing penetration depth of light by 3.3 mm and treatment volumes 3-fold. The photodynamic threshold for lung exposed to 5-ALA was consistent with other malignancies. Chlorin e6 levels were undetectable in lung tissue and did not demonstrate photodynamic-induced necrosis. CONCLUSIONS Light penetration with low cellular perfusate is significantly greater and could enable treatments for diffuse disease. This data aids photodynamic treatment planning and will guide clinical translation of photodynamic therapy protocols in the lung, especially during lung perfusion.
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Affiliation(s)
- Khaled T Ramadan
- University of Toronto, Faculty of Medicine, Department of Surgery, 149 College Street, Toronto M5T 1P5, Ontario, Canada
| | - Christopher McFadden
- University of Toronto, Faculty of Medicine, Department of Medical Biophysics, 101 College Street, Toronto M5G 1L7, Ontario, Canada
| | - Bruno Gomes
- Princess Margaret Cancer Centre, University Health Network, 101 College St, Toronto M5G 2C4, Ontario, Canada
| | - Fynn Schwiegelshohn
- University of Toronto, Faculty of Applied Science and Engineering, Department of Electrical and Computer Engineering, 10 Kings College Road, Toronto M5S 3G4, Ontario, Canada
| | - Rafaela V P Ribeiro
- Princess Margaret Cancer Centre, University Health Network, 101 College St, Toronto M5G 2C4, Ontario, Canada
| | - Harley H L Chan
- Techna Institute, Guided Therapeutics Program, University Health Network, 101 College Street, Toronto M5G 1L7, Ontario, Canada
| | - Vaughn Betz
- University of Toronto, Faculty of Applied Science and Engineering, Department of Electrical and Computer Engineering, 10 Kings College Road, Toronto M5S 3G4, Ontario, Canada
| | - Marcelo Cypel
- University of Toronto, Faculty of Medicine, Department of Surgery, 149 College Street, Toronto M5T 1P5, Ontario, Canada; Princess Margaret Cancer Centre, University Health Network, 101 College St, Toronto M5G 2C4, Ontario, Canada
| | - Lothar Lilge
- University of Toronto, Faculty of Medicine, Department of Medical Biophysics, 101 College Street, Toronto M5G 1L7, Ontario, Canada; Princess Margaret Cancer Centre, University Health Network, 101 College St, Toronto M5G 2C4, Ontario, Canada.
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A model to assess acute and delayed lung toxicity of oxaliplatin during in vivo lung perfusion. J Thorac Cardiovasc Surg 2020; 161:1626-1635. [PMID: 32354628 DOI: 10.1016/j.jtcvs.2020.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/06/2020] [Accepted: 03/08/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the dose-limiting toxicity of oxaliplatin chemotherapy delivered by in vivo lung perfusion (IVLP). To allow assessment of subacute toxicities, we aimed to develop a 72-hour porcine IVLP survival model. METHODS In total, 12 Yorkshire male pigs were used. Left lung IVLP was performed for 3 hours. At 72 hours postoperatively, computed tomography imaging of the lungs was performed before the pigs were killed. Lung physiology, airway dynamics, gross appearance, and histology were assessed before and during IVLP, at reperfusion, and when the pigs were euthanized. An accelerated titration dose-escalation study design was employed whereby oxaliplatin doses were sequentially doubled provided no clinically significant toxicity was observed, defined as an arterial partial pressure of oxygen to fraction of inspired oxygen ratio <300 mm Hg or severe acute lung injury on biopsy. RESULTS After an initial training phase, no mortality or adverse events related to the procedure were observed. There was no lung injury observed at the time of IVLP for any case. At sacrifice, clinically significant lung injury was observed at 80 mg/L oxaliplatin, with an arterial partial pressure of oxygen to fraction of inspired oxygen ratio of 112 mm Hg. Mild and subclinical lung injury was observed at 40 mg/L, with this dose being repeated to confirm safety. CONCLUSIONS A stable and reproducible porcine 3-day IVLP survival model was established that will allow toxicity assessment of agents delivered by IVLP. Oxaliplatin delivered by IVLP showed delayed-onset toxicity that was not apparent at the time of reperfusion, with a maximal-tolerated dose of 40 mg/L. This information will inform initiation of a clinical trial examining IVLP delivery of oxaliplatin at our institution.
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Implementation of an experimental isolated lung perfusion model on surgically resected human lobes. Sci Rep 2019; 9:12193. [PMID: 31434960 PMCID: PMC6704181 DOI: 10.1038/s41598-019-48719-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/12/2019] [Indexed: 01/12/2023] Open
Abstract
Isolated lung perfusion (ILP) is an ideal model to study treatment effects on a variety of pathologies. As published research mostly relies on rejected donor lungs or animal organs, this study investigates the use of surgically resected human lobes as an alternative and novel model for personalized experimental research. Ten surgically resected lobes were perfused in acellular and normothermic condition. The indication for surgery was lung cancer. Perfusion and ventilation were adapted to the size of the lobes and both functional and metabolic parameters were assessed during ILP. Patients (age 67.5 y (59–81)|♀n = 3|♂n = 7) underwent anatomic pulmonary lobectomy. Ischemic time between arterial ligation and ILP was 226 minutes (161–525). Median duration of ILP was 135 (87–366) minutes. Gas exchange and mechanical respiratory parameters remained steady during ILP (pulmonary venous pO2 196(151–219) mmHg | peak AWP: 14.5(11–22) cmH2O). Metabolism stayed constant during ILP (Glucose consumption: 1.86 mg/min/LTLC (95%CI: −2.09 to −1.63) | lactate production: 0.005 mmol/min/ LTLC (95%CI: 0.004 to 0.007)). ILP of surgically resected human lobes is a feasible and promising method. By maintaining a near physiological setting, this model may pave the way for future experimental lung research including cancer research, transplantation, physiology, pharmacology and mechanical ventilation.
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Multicenter Phase II Clinical Trial of Isolated Lung Perfusion in Patients With Lung Metastases. Ann Thorac Surg 2019; 108:167-174. [DOI: 10.1016/j.athoracsur.2019.02.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 12/29/2018] [Accepted: 02/08/2019] [Indexed: 12/27/2022]
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Grootenboers MJJH, Heeren J, van Putte BP, Hendriks JMH, van Boven WJ, Van Schil PEY, Schramel FMNH. Isolated lung perfusion for pulmonary metastases, a review and work in progress. Perfusion 2016; 21:267-76. [PMID: 17201081 DOI: 10.1177/0267659106073984] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pulmonary metastasectomy is a widely accepted treatment for many patients with pulmonary metastases from various solid tumors. Nevertheless, 5–year survival is disappointing, with rates of 25–40%, and many patients develop recurrences. Isolated lung perfusion (ILuP) is a promising new technique to deliver high–dose chemotherapy to the lungs, while minimising systemic toxicities. This procedure is technically safe and feasible; however, clinical value and efficacy remain unclear. The aim of this paper is to give a review of literature on ILuP in humans, and to describe the development of the perfusion procedure in our institute.
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Abstract
Isolated lung perfusion (ILP) has been examined and developed in lung transplantation and thoracic oncology research. In lung transplantation, ILP has been used to assess physiologic integrity of donor lungs after removal from the donor, and it has also been proposed as a method for active treatment and repair of injured unsuitable donor organs ex vivo. ILP is attractive as a concept to deliver high-dose chemotherapy to treat pulmonary metastatic disease, referred to as in vivo lung perfusion. This article focuses on the rationale, technical aspects, and experimental and clinical experience of in vivo lung perfusion. A perspective on the future application of these techniques is described.
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Affiliation(s)
- Marcelo Cypel
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, UHN, University of Toronto, 200 Elizabeth Street, 9N-969, Toronto, Ontario M5G 2C4, Canada.
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, UHN, University of Toronto, 200 Elizabeth Street, 9N-969, Toronto, Ontario M5G 2C4, Canada
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Phase II multicenter clinical trial of pulmonary metastasectomy and isolated lung perfusion with melphalan in patients with resectable lung metastases. J Thorac Oncol 2015; 9:1547-53. [PMID: 25105436 DOI: 10.1097/jto.0000000000000279] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The 5-year overall survival rate of patients undergoing complete surgical resection of pulmonary metastases (PM) from colorectal cancer (CRC) and sarcoma remains low (20-50%). Local recurrence rate is high (48-66%). Isolated lung perfusion (ILuP) allows the delivery of high-dose locoregional chemotherapy with minimal systemic leakage to improve local control. METHODS From 2006 to 2011, 50 patients, 28 male, median age 57 years (15-76), with PM from CRC (n = 30) or sarcoma (n = 20) were included in a phase II clinical trial conducted in four cardiothoracic surgical centers. In total, 62 ILuP procedures were performed, 12 bilaterally, with 45 mg of melphalan at 37°C, followed by resection of all palpable PM. Survival was calculated according to the Kaplan-Meier method. RESULTS Operative mortality was 0%, and 90-day morbidity was mainly respiratory (grade 3: 42%, grade 4: 2%). After a median follow-up of 24 months (3-63 mo), 18 patients died, two without recurrence. Thirty patients had recurrent disease. Median time to local pulmonary progression was not reached. The 3-year overall survival and disease-free survival were 57% ± 9% and 36% ± 8%, respectively. Lung function data showed a decrease in forced expiratory volume in 1 second and diffusing capacity of the alveolocapillary membrane of 21.6% and 25.8% after 1 month, and 10.4% and 11.3% after 12 months, compared with preoperative values. CONCLUSION Compared with historical series of PM resection without ILuP, favorable results are obtained in terms of local control without long-term adverse effects. These data support the further investigation of ILuP as additional treatment in patients with resectable PM from CRC or sarcoma.
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Vogl TJ, Shafinaderi M, Zangos S, Lindemayr S, Vatankhah K. Regional chemotherapy of the lung: transpulmonary chemoembolization in malignant lung tumors. Semin Intervent Radiol 2014; 30:176-84. [PMID: 24436534 DOI: 10.1055/s-0033-1342959] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Standard treatment options in patients with lung cancer and pulmonary metastases are surgery, radiotherapy, chemotherapy, and immunotherapy. For reducing clinical complications of surgery and achieving a better local response, transpulmonary chemoembolization of the lungs is a possible interventional technique in which anticancer drugs are administered directly into a tumor through its feeding vessels followed by occlusive agents that are injected through the delivery catheter for blocking the vessel. This allows a longer contact period in the tumor with a higher cytostatic drug concentration. The technique is safe and results present promising local response rates, but the influence on survival is still questionable. This article describes the current role of intravascular therapies in the treatment of pulmonary malignancies.
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Affiliation(s)
- Thomas J Vogl
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Mohammad Shafinaderi
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Stefan Zangos
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Sebastian Lindemayr
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
| | - Khashayar Vatankhah
- Institute for Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt am Main, Germany
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dos Santos PR, Iskender I, Machuca T, Hwang D, dePerrot M, Liu M, Keshavjee S, Waddell TK, Cypel M. Modified in vivo lung perfusion allows for prolonged perfusion without acute lung injury. J Thorac Cardiovasc Surg 2014; 147:774-81: discussion 781-2. [DOI: 10.1016/j.jtcvs.2013.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 09/19/2013] [Accepted: 10/06/2013] [Indexed: 11/26/2022]
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Gadaleta CD, Solbiati L, Mattioli V, Rubini G, Fazio V, Goffredo V, Vinciarelli G, Gadaleta-Caldarola G, Canniello E, Armenise F, D'Aluisio L, Gaudiano A, Ranieri G, Goldberg SN. Unresectable lung malignancy: combination therapy with segmental pulmonary arterial chemoembolization with drug-eluting microspheres and radiofrequency ablation in 17 patients. Radiology 2012; 267:627-37. [PMID: 23249572 DOI: 10.1148/radiol.12120198] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE To evaluate the feasibility, safety, and effectiveness of combining segmental pulmonary arterial chemoembolization (SPACE) and percutaneous radiofrequency (RF) ablation in patients with unresectable lung neoplasms or patients with resectable neoplasms who refused surgery and to compare the local tumor progression (LTP) rate with that in previous studies of RF ablation alone. MATERIALS AND METHODS After institutional review board approval and informed consent, 17 patients with primary and metastatic lung cancer were enrolled in this prospective study. Between January 2008 and February 2011, 20 nodules (median diameter, 3.0 cm; range, 2.0-5.0 cm) were treated during 19 sessions. Antineoplastic agents loaded on 50-100-µm microspheres were selectively infused into specific pulmonary arteries. Percutaneous computed tomography (CT)-guided RF ablation of lung nodules was performed 48 hours after SPACE. Follow-up consisted of enhanced CT 48 hours after combination treatment was completed, after 30 days, and every 3 months thereafter. Fluorine 18 fluorodeoxyglucose positron emission tomography was performed 3 months after combination therapy and then every 6 months. The t test was used to compare groups. RESULTS Technical success was achieved in 100% of cases. Ventilation-lung single photon emission computed tomography showed a wide area without ventilation in the lung parenchyma treated with SPACE. The LTP rate was 21% (three of 14 nodules) in 3-5-cm-diameter tumors and 0% (zero of six nodules) in tumors of 3 cm or smaller in diameter. Complete response was achieved in 65% (11 of 17) of patients at minimum follow-up of 6 months. Overall, treatment was well tolerated. Major complications were pneumothorax in five of 19 sessions (26%) and one bronchopleural fistula (one of 19, 5%). No treatment-related changes in general lung function were noted. CONCLUSION Combination therapy with RF ablation after SPACE to treat unresectable lung tumors is technically feasible, safe, and effective and may represent an advantage over RF ablation alone.
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Affiliation(s)
- Cosmo D Gadaleta
- Interventional Radiology and Medical Oncology Unit, National Cancer Research Centre Istituto Tumori Giovanni Paolo II Bari, Viale Orazio Flacco 65, 70124 Bari, Italy.
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Den Hengst WA, Hendriks JMH, Van Hoof T, Heytens K, Guetens G, de Boeck G, Lardon F, Van Schil PEY. Selective pulmonary artery perfusion with melphalan is equal to isolated lung perfusion but superior to intravenous melphalan for the treatment of sarcoma lung metastases in a rodent model. Eur J Cardiothorac Surg 2012; 42:341-7; discussion 347. [DOI: 10.1093/ejcts/ezs017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cheng C, Wang Y, Haouala A, Debefve E, Andrejevic Blant S, Krueger T, Gonzalez M, Ballini JP, Peters S, Decosterd L, van den Bergh H, Ris HB, Perentes JY. Photodynamic therapy enhances liposomal doxorubicin distribution in tumors during isolated perfusion of rodent lungs. Eur Surg Res 2011; 47:196-204. [PMID: 21986386 DOI: 10.1159/000330744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 06/17/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Photodynamic therapy (PDT) at low drug-light conditions can enhance the transport of intravenously injected macromolecular therapeutics through the tumor vasculature. Here we determined the impact of PDT on the distribution of liposomal doxorubicin (Liporubicin™) administered by isolated lung perfusion (ILP) in sarcomas grown on rodent lungs. METHODS A syngeneic methylcholanthrene-induced sarcoma cell line was implanted subpleurally in the left lung of Fischer rats. Treatment schemes consisted in ILP alone (400 μg of Liporubicin), low-dose (0.0625 mg/kg Visudyne®, 10 J/cm(2) and 35 mW/cm(2)) and high-dose left lung PDT (0.125 mg/kg Visudyne, 10 J/cm(2) and 35 mW/cm(2)) followed by ILP (400 μg of Liporubicin). The uptake and distribution of Liporubicin in tumor and lung tissues were determined by high-performance liquid chromatography and fluorescence microscopy in each group. RESULTS Low-dose PDT significantly improved the distribution of Liporubicin in tumors compared to high-dose PDT (p < 0.05) and ILP alone (p < 0.05). However, both PDT pretreatments did not result in a higher overall drug uptake in tumors or a higher tumor-to-lung drug ratio compared to ILP alone. CONCLUSIONS Intraoperative low-dose Visudyne-mediated PDT enhances liposomal doxorubicin distribution administered by ILP in sarcomas grown on rodent lungs which is predicted to improve tumor control by ILP.
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Affiliation(s)
- C Cheng
- Division of Thoracic and Vascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Baylatry MT, Pelage JP, Wassef M, Ghegediban H, Joly AC, Lewis A, Lacombe P, Fernandez C, Laurent A. Pulmonary artery chemoembolization in a sheep model: Evaluation of performance and safety of irinotecan eluting beads (DEB-IRI). J Biomed Mater Res B Appl Biomater 2011; 98:351-9. [DOI: 10.1002/jbm.b.31858] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 02/24/2011] [Indexed: 12/16/2022]
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Regional Lung Chemotherapy Techniques. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:1-9. [DOI: 10.1097/imi.0b013e31820b1e63] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Selective delivery of chemotherapy to an affected organ or region of the body promises improved drug efficacy for the targeted area while minimizing the systemic exposure and toxicity. Several intravascular surgical techniques to achieve targeted regional lung chemotherapy have been developed. Investigations have been carried out to determine the feasibility, safety, and efficacy of these techniques in the primary or adjuvant setting with the intent to palliate or cure. This overview describes the history, rationale, technical aspects, and clinical experience of four regional lung chemotherapy techniques delivered by vascular manipulations including bronchial artery infusion, pulmonary artery chemoembolization, isolated lung perfusion, and lung suffusion.
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Mallick R, Demmy T. Regional Lung Chemotherapy Techniques. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Reema Mallick
- Northeastern Ohio Universities College of Medicine, Rootstown, OH USA
| | - Todd Demmy
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY USA
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Abstract
Even after complete surgical resection of pulmonary metastases, many patients develop recurrent disease in the thorax despite the use of systemic chemotherapy, dosage of which is limited because of systemic toxicity. Although subsequent operations are feasible and good long-term results have been reported, sufficient functional lung parenchyma must remain. For this reason, new treatment strategies are explored. Similar to isolated limb and liver perfusion, isolated lung perfusion (ILuP) is a promising surgical technique for the delivery of high-dose chemotherapy with minimal systemic toxicity. The use of biologic response modifiers, such as tumor necrosis factor, is also feasible. ILuP with high-dose chemotherapy has proven to be highly effective in the experimental models of pulmonary metastases with a superior survival advantage compared with systemic treatment. Lung levels are significantly higher after ILuP compared with intravenous therapy without systemic exposure. Phase I human studies have shown that ILuP is technically feasible with low morbidity and without compromising the patient's pulmonary function. Further clinical studies are necessary to determine its definitive effect on local recurrence, long-term toxicity, pulmonary function, and survival.
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Abstract
Pulmonary metastases are common in patients following resection for soft tissue sarcoma. Pulmonary resection of metastatic soft tissue sarcomas is widely practiced in surgical oncology. No randomized phase III trials are available, and data for this review were retrieved only from retrospective studies. This article addresses the issues of patient selection, surgical technique, and adjuvant chemotherapy, and provides the surgical oncologist with a current review of pulmonary metastasectomy in metastatic soft tissue sarcoma. In summary, there is a substantial body of evidence demonstrating that resection of soft tissue pulmonary metastases can be performed safely and with a low mortality rate. For a subset of highly selected patients, the overall results of a 5-year actuarial survival rate ranged between 25% and 37.6%. These outcomes exceed those normally associated with metastatic soft tissue sarcoma and are well comparable with surgical resection for other malignancies.
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Vogl TJ, Lehnert T, Zangos S, Eichler K, Hammerstingl R, Korkusuz H, Lindemayr S. Transpulmonary chemoembolization (TPCE) as a treatment for unresectable lung metastases. Eur Radiol 2008; 18:2449-55. [DOI: 10.1007/s00330-008-1056-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Revised: 04/02/2008] [Accepted: 04/07/2008] [Indexed: 11/28/2022]
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Distribution of Free and Liposomal Doxorubicin After Isolated Lung Perfusion in a Sarcoma Model. Ann Thorac Surg 2008; 85:1225-32. [DOI: 10.1016/j.athoracsur.2007.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2006] [Revised: 12/03/2007] [Accepted: 12/10/2007] [Indexed: 11/21/2022]
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Lindemayr S, Lehnert T, Korkusuz H, Hammerstingl R, Vogl TJ. Transpulmonary chemoembolization: a novel approach for the treatment of unresectable lung tumors. Tech Vasc Interv Radiol 2008; 10:114-9. [PMID: 18070689 DOI: 10.1053/j.tvir.2007.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the technique of transpulmonary chemoembolization for the palliative treatment of unresectable lung tumors. Early utilization of this method has resulted in reduction in tumor volume and alleviation of patient symptoms. After superselective catheterization, cytotoxic agents are administered, and the pulmonary arterial supply of the tumor is occluded by injection of microspheres and ethiodized oil. Emerging data suggest that this approach is well tolerated.
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Affiliation(s)
- Sebastian Lindemayr
- Department of Diagnostic and Interventional Radiology, University of Frankfurt, Frankfurt, Germany
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Grootenboers MJH, Hendriks JMH, van Boven WJ, Knibbe CAJ, van Putte B, Stockman B, De Bruijn E, Vermorken JB, Van Schil PEY, Schramel FM. Pharmacokinetics of isolated lung perfusion with melphalan for resectable pulmonary metastases, a phase I and extension trial. J Surg Oncol 2008; 96:583-9. [PMID: 17999399 DOI: 10.1002/jso.20838] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Isolated lung perfusion (ILuP) with melphalan was performed under normo- and hyperthermic conditions combined with pulmonary metastasectomy for patients with resectable lung metastases. We present the results of pharmacokinetic analysis of a phase I and extension trial. METHODS Twenty-one procedures of ILuP with melphalan were performed in the phase I trial according to a dose-escalation schedule under normothermic and hyperthermic conditions followed by surgical resection of pulmonary metastases. In an extension trial 8 additional procedures with 15 and 45 mg melphalan were performed under hyperthermic conditions. Samples of serum, perfusate, lung, and tumor tissue were obtained. RESULTS High perfusate concentrations of melphalan were recorded in contrast to low systemic concentrations. Marked interindividual variability was observed in melphalan concentrations in perfusate, tumor, and lung tissue. Statistically significant correlation between melphalan dose, and perfusate area under the concentration-time curve (R(2) = 0.578, P = 0.001) and lung tissue concentrations (R(2) = 0.459, P = 0.028) were noted. No significant correlation between melphalan dose and tumor tissue concentrations could be established. CONCLUSION Isolated lung perfusion effectively delivers high doses of melphalan to the lung and tumor tissues with minimal systemic levels. Significant correlation between perfused melphalan dose, perfusate area under the concentration-time curve and lung tissue melphalan concentrations were observed.
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Donington JS. Metastatic Cancer to Lung. Oncology 2007. [DOI: 10.1007/0-387-31056-8_93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Krueger T, Kuemmerle A, Andrejevic-Blant S, Yan H, Pan Y, Ballini JP, Klepetko W, Decosterd LA, Stupp R, Ris HB. Antegrade Versus Retrograde Isolated Lung Perfusion: Doxorubicin Uptake and Distribution in a Sarcoma Model. Ann Thorac Surg 2006; 82:2024-30. [PMID: 17126104 DOI: 10.1016/j.athoracsur.2006.05.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 05/10/2006] [Accepted: 05/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Antegrade and retrograde doxorubicin-based isolated lung perfusions were compared in rodents bearing a sarcomatous tumor in the perfused lung. Inasmuch as these tumors derive their vascularization from the bronchial artery system, we hypothesized that retrograde isolated lung perfusion through the pulmonary vein might result in an improved tumor drug uptake. METHODS Single-pass antegrade (n = 9) and retrograde (n = 9) isolated left lung perfusions were performed with 100 microg of doxorubicin in Fischer rats 10 days after subpleural tumor cell injection. The perfusion, washout, and recirculation times were 20, 10, and 60 minutes, respectively, followed by harvesting of the lung. The doxorubicin concentration and compartmental distribution in the tumor and in normal parenchyma of each perfused lung were measured by high-pressure liquid chromatography (6 animals of each group) and fluorescence microscopy (3 animals of each group). RESULTS Doxorubicin concentration and pattern of doxorubicin-based fluorescence signaling were comparable for both perfusion techniques in normal lung tissue. Antegrade and retrograde isolated lung perfusion resulted in similar tumor drug uptake, which was lower than in normal lung parenchyma, and in weak and sporadic fluorescence signaling emerging from the tumor periphery and from blood vessels situated within the tumor tissue. CONCLUSIONS Retrograde isolated lung perfusion did not confer a better doxorubicin uptake in the tumor as compared with antegrade lung perfusion despite the fact that the tumor vascularization in this model is based on the bronchial artery circulation.
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Affiliation(s)
- Thorsten Krueger
- Division of Thoracic Surgery, Multidisciplinary Oncology Center, University Hospital, Lausanne, Switzerland.
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Hendriks JMH, Van Putte BP, Grootenboers M, Van Boven WJ, Schramel F, Van Schil PEY. Isolated lung perfusion for pulmonary metastases. Thorac Surg Clin 2006; 16:185-98, vii. [PMID: 16805207 DOI: 10.1016/j.thorsurg.2005.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Isolated lung perfusion is an experimental surgical technique evaluated for the delivery of high-dose chemotherapy to improve 5-year survival after pulmonary metastasectomy. Extensive experimental work in animal models has demonstrated superior pharmacokinetics and efficacy compared with systemic therapy. Phase I clinical trials of isolated lung perfusion found a maximum tolerated dose**** of TNF-alpha, doxorubicin, cisplatin, and melphalan, whereas the combination of isolated lung perfusion with a complete metastasectomy was feasible. The combination of isolated lung perfusion and regional lung perfusion techniques needs further investigation.
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Affiliation(s)
- Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Wilrijkstraat 10 B-2650, Edegem, Belgium.
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Krueger T, Kuemmerle A, Kosinski M, Denys A, Magnusson L, Stupp R, Delaloye AB, Klepetko W, Decosterd L, Ris HB, Dusmet M. Cytostatic lung perfusion results in heterogeneous spatial regional blood flow and drug distribution: Evaluation of different cytostatic lung perfusion techniques in a porcine model. J Thorac Cardiovasc Surg 2006; 132:304-11. [PMID: 16872954 DOI: 10.1016/j.jtcvs.2005.12.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 12/22/2005] [Accepted: 12/30/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Comparison of doxorubicin uptake, leakage and spatial regional blood flow, and drug distribution was made for antegrade, retrograde, combined antegrade and retrograde isolated lung perfusion, and pulmonary artery infusion by endovascular inflow occlusion (blood flow occlusion), as opposed to intravenous administration in a porcine model. METHODS White pigs underwent single-pass lung perfusion with doxorubicin (320 mug/mL), labeled 99mTc-microspheres, and Indian ink. Visual assessment of the ink distribution and perfusion scintigraphy of the perfused lung was performed. 99mTc activity and doxorubicin levels were measured by gamma counting and high-performance liquid chromatography on 15 tissue samples from each perfused lung at predetermined localizations. RESULTS Overall doxorubicin uptake in the perfused lung was significantly higher (P = .001) and the plasma concentration was significantly lower (P < .0001) after all isolated lung perfusion techniques, compared with intravenous administration, without differences between them. Pulmonary artery infusion (blood flow occlusion) showed an equally high doxorubicin uptake in the perfused lung but a higher systemic leakage than surgical isolated lung perfusion (P < .0001). The geometric coefficients of variation of the doxorubicin lung tissue levels were 175%, 279%, 226%, and 151% for antegrade, retrograde, combined antegrade and retrograde isolated lung perfusion, and pulmonary artery infusion by endovascular inflow occlusion (blood flow occlusion), respectively, compared with 51% for intravenous administration (P = .09). 99mTc activity measurements of the samples paralleled the doxorubicin level measurements, indicating a trend to a more heterogeneous spatial regional blood flow and drug distribution after isolated lung perfusion and blood flow occlusion compared with intravenous administration. CONCLUSIONS Cytostatic lung perfusion results in a high overall doxorubicin uptake, which is, however, heterogeneously distributed within the perfused lung.
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Affiliation(s)
- Thorsten Krueger
- Department of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Brown DB, Cai SR, Fundakowski CE, Zamboni WC, Strychor S, McLeod HL. Pharmacokinetics after Endovascular Lung Perfusion with Cisplatin. J Vasc Interv Radiol 2006; 17:883-8. [PMID: 16687755 DOI: 10.1097/01.rvi.0000209346.88944.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Endovascular lung perfusion (ELP) is a technique designed to deliver high doses of cisplatin via the pulmonary artery for the treatment of lung tumors. The purpose of the current study was to evaluate variables that affect adduct formation. MATERIALS AND METHODS Thirteen swine underwent ELP. The first group (n = 6) underwent infusion of 150 mg cisplatin diluted to 0.5 mg/mL via a balloon occlusion catheter in the left pulmonary artery. Uptake was compared with that seen with systemic infusion. A second group (n = 7) underwent bilateral sequential infusion of the left pulmonary artery, followed by the right. Cisplatin (150 mg) was infused at one of three concentrations: 1 mg/mL (n = 5 lungs), 0.67 mg/mL (n = 5 lungs), or 0.5 mg/mL (n = 4 lungs). The Pearson coefficient was used to correlate uptake with infusion time, infusate concentration, animal weight, and initial mean pulmonary artery pressure. RESULTS In the first group, cisplatin uptake in the control lung was less than 8% of that in the study lung. Infusion times for both groups ranged from 3 minutes to 56 minutes. Increases in infusion time correlated with increased adduct levels (r = 0.831; P < .0001). Mean uptake at concentrations of 0.5, 0.67, and 1 mg/mL were 25.79, 12.43, and 13.12 fmol/mug, respectively. There was no significant correlation between pulmonary adduct levels and infusate concentration (r = 0.106; P = .72). Animal weight and initial mean pulmonary artery pressure were not correlated with adduct formation. CONCLUSIONS ELP with longer infusions of cisplatin may lead to greater adduct formation in pulmonary tissues. Changes in concentration of the infusate do not affect uptake of cisplatin. Hemodynamic parameters do not affect cisplatin uptake.
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Affiliation(s)
- Daniel B Brown
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Box 8131, St. Louis, Missouri 63110, USA.
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Hendriks JMH, Grootenboers MJJH, Schramel FMNH, van Boven WJ, Stockman B, Seldenrijk CA, ten Broecke P, Knibbe CAJ, Slee P, De Bruijn E, Vlaeminck R, Heeren J, Vermorken JB, van Putte B, Romijn S, Van Marck E, Van Schil PEY. Isolated Lung Perfusion With Melphalan for Resectable Lung Metastases: A Phase I Clinical Trial. Ann Thorac Surg 2004; 78:1919-26; discussion 1926-7. [PMID: 15561001 DOI: 10.1016/j.athoracsur.2004.05.058] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2004] [Indexed: 11/20/2022]
Abstract
BACKGROUND Current 5-year survival after complete resection of pulmonary metastases is 20% to 40%, and many patients develop intrathoracic recurrences. Isolated lung perfusion is an experimental technique to deliver high-dose chemotherapy to the lung without systemic exposure. A phase I trial of isolated lung perfusion with melphalan (MN) combined with pulmonary metastasectomy for resectable lung metastases was conducted to define the dose-limiting toxicity and maximum tolerated dose. METHODS From May 2001 to August 2003, 16 patients underwent isolated lung perfusion with MN, followed by surgical resection of lung metastases. Patients were treated with increasing MN doses (15, 30, 45, and 60 mg). For each dose level, normothermia (37 degrees C) and hyperthermia (42 degrees C) were evaluated (n = 3 per level). Serum samples were obtained during the procedure. Pulmonary, hematologic, and nonhematologic toxicities were recorded. The primary tumor was colorectal in 7 patients, renal in 5, sarcoma in 3, and salivary gland in 1. Isolated lung perfusion was performed unilaterally in 11 patients, and staged bilaterally in 5. RESULTS In total, 21 procedures of isolated lung perfusion with complete metastasectomy were performed without technical difficulties. Operative mortality was 0%, and no systemic toxicity was encountered. Grade 3 pulmonary toxicity developed at a dose of 60 mg of MN at 37 degrees C in 2 of 3 patients at this dose, terminating the trial. CONCLUSIONS Isolated lung perfusion with MN combined with pulmonary metastasectomy is feasible. Dose-limiting toxicity occurred at a dose of 60 mg of MN at 37 degrees C, and the maximum tolerated dose was set at 45 mg of MN at 42 degrees C.
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Affiliation(s)
- Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
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Van Putte BP, Hendriks JMH, Romijn S, Van Schil PEY. Isolated lung perfusion for the treatment of pulmonary metastases current mini-review of work in progress. Surg Oncol 2003; 12:187-93. [PMID: 12957622 DOI: 10.1016/s0960-7404(03)00039-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Surgical resection of lung metastases is a widely accepted procedure but long-term results are disappointing with a 5-year survival rate of approximately 40%. Pulmonary metastasectomy is only indicated when complete resection can be achieved. A better survival is reported in patients with a single metastasis or a disease-free survival of more than 3 years. Intravenous chemotherapy has no major impact on survival because high-dose therapy is limited by systemic side-effects. Isolated lung perfusion has the advantage of both selectively delivering an agent into the lung while diverting the venous effluent. This allows the drug to be given in a significantly higher dose compared to intravenous therapy, while drug levels in critical organs are kept low enough to avoid significant morbidity. Isolated lung perfusion has proven to be effective for the treatment of lung metastases in animal models while the procedure is technically safe in humans. However, the real clinical value and survival benefit remain to be determined in ongoing clinical trials.The aim of this paper was to update the literature on isolated lung perfusion for the treatment of lung metastases. Furthermore, some proposals are made in order to improve the ultimate prognosis of these patients.
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Affiliation(s)
- Bart P Van Putte
- Department of Thoracic and Vascular Surgery, University Hospital Antwerp, Wilrijkstraat 10, B-2650, Edegem, Belgium
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Kümmerle A, Krueger T, Dusmet M, Vallet C, Pan Y, Ris HB, Decosterd LA. A validated assay for measuring doxorubicin in biological fluids and tissues in an isolated lung perfusion model: matrix effect and heparin interference strongly influence doxorubicin measurements. J Pharm Biomed Anal 2003; 33:475-94. [PMID: 14550866 DOI: 10.1016/s0731-7085(03)00300-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Doxorubicin is an antineoplasic agent active against sarcoma pulmonary metastasis, but its clinical use is hampered by its myelotoxicity and its cumulative cardiotoxicity, when administered systemically. This limitation may be circumvented using the isolated lung perfusion (ILP) approach, wherein a therapeutic agent is infused locoregionally after vascular isolation of the lung. The influence of the mode of infusion (anterograde (AG): through the pulmonary artery (PA); retrograde (RG): through the pulmonary vein (PV)) on doxorubicin pharmacokinetics and lung distribution was unknown. Therefore, a simple, rapid and sensitive high-performance liquid chromatography method has been developed to quantify doxorubicin in four different biological matrices (infusion effluent, serum, tissues with low or high levels of doxorubicin). The related compound daunorubicin was used as internal standard (I.S.). Following a single-step protein precipitation of 500 microl samples with 250 microl acetone and 50 microl zinc sulfate 70% aqueous solution, the obtained supernatant was evaporated to dryness at 60 degrees C for exactly 45 min under a stream of nitrogen and the solid residue was solubilized in 200 microl of purified water. A 100 microl-volume was subjected to HPLC analysis onto a Nucleosil 100-5 microm C18 AB column equipped with a guard column (Nucleosil 100-5 microm C(6)H(5) (phenyl) end-capped) using a gradient elution of acetonitrile and 1-heptanesulfonic acid 0.2% pH 4: 15/85 at 0 min-->50/50 at 20 min-->100/0 at 22 min-->15/85 at 24 min-->15/85 at 26 min, delivered at 1 ml/min. The analytes were detected by fluorescence detection with excitation and emission wavelength set at 480 and 550 nm, respectively. The calibration curves were linear over the range of 2-1000 ng/ml for effluent and plasma matrices, and 0.1 microg/g-750 microg/g for tissues matrices. The method is precise with inter-day and intra-day relative standard deviation within 0.5 and 6.7% and accurate with inter-day and intra-day deviations between -5.4 and +7.7%. The in vitro stability in all matrices and in processed samples has been studied at -80 degrees C for 1 month, and at 4 degrees C for 48 h, respectively. During initial studies, heparin used as anticoagulant was found to profoundly influence the measurements of doxorubicin in effluents collected from animals under ILP. Moreover, the strong matrix effect observed with tissues samples indicate that it is mandatory to prepare doxorubicin calibration standard samples in biological matrices which would reflect at best the composition of samples to be analyzed. This method was successfully applied in animal studies for the analysis of effluent, serum and tissue samples collected from pigs and rats undergoing ILP.
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Affiliation(s)
- A Kümmerle
- Division de Pharmacalogie clinique, Laboratoire BH 18-218, Département de Médecine, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
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Van Putte BP, Hendriks JMH, Romijn S, Pauwels B, De Boeck G, Guetens G, De Bruijn E, Van Schil PEY. Pharmacokinetics after pulmonary artery perfusion with gemcitabine. Ann Thorac Surg 2003; 76:1036-40; discussion 1040. [PMID: 14529980 DOI: 10.1016/s0003-4975(03)00839-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Isolated lung perfusion (ILuP) proved to be superior for the treatment of lung metastases compared with intravenous (i.v.) injection. However its invasive character limits repetitive treatment. Blood flow occlusion (BFO) as a regional therapy with gemcitabine (GCB) was evaluated in a rat model. Lung levels of GCB were examined with different exposure times and flow rates and compared with ILuP and i.v.. Cell kill was studied in vitro. METHODS In vitro survival of CC531 adenocarcinoma cells was determined after 10, 20, and 40 minutes of exposure to GCB. In vivo 48 Wag/Rij rats underwent BFO with GCB at a rate of 0.2 mL/min and 0.5 mL/min during 10, 20, 30, and 40 minutes. Statistical analysis was performed using Student's t test. RESULTS In vitro, the dose of GCB resulting in 50% growth inhibition was 9.1 microg/mL, 7.2 microg/mL, and 2.2 microg/mL after 10, 20, and 40 minutes exposure respectively. In vivo, no significant difference in lung levels of GCB was observed between a flow rate of 0.2 mL/min compared with 0.5 mL/min at any exposure time point (p < 0.05). Lung tissue was saturated after 20 minutes. Blood flow occlusion resulted in a lower plasma levels and higher lung levels of GCB compared with i.v. injection of the maximal tolerated dose of 40 mg. CONCLUSIONS Growth inhibition of CC531 cells in vitro increased with exposure time while lung tissue was saturated after 20 minutes of BFO. No difference in GCB lung levels were seen after BFO compared with ILuP. Systemic exposure after i.v. injection was higher compared with BFO but did not result in higher lung levels.
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Affiliation(s)
- Bart P Van Putte
- Department of Thoracic and Vascular Surgery, University Hospital, Antwerp, Edegem, Belgium
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Mcunu ANS, Pass HI. Metastatic Cancer to the Lung. Surg Oncol 2003. [DOI: 10.1007/0-387-21701-0_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
As the lungs are a filter for the entire circulation, they are a common site for metastatic disease. Although never proven by a prospective randomized trial, surgical resection is a widely accepted treatment for pulmonary metastases on the condition that a complete resection can be obtained. However, many patients will develop recurrent disease in the thorax despite the use of systemic chemotherapy, dosage of which is limited due to systemic toxicity. As isolated limb and liver perfusion, isolated lung perfusion is an attractive and promising surgical technique for the delivery of high-dose chemotherapy with minimal systemic toxicity. The use of biological response modifiers, like tumour necrosis factor, is also feasible. Isolated lung perfusion has proven to be highly effective in rat models of pulmonary metastases with a clear survival advantage. Lung levels are significantly higher after isolated lung perfusion compared to intravenous therapy without systemic exposure. Preliminary human studies have shown that isolated lung perfusion is technically feasible with low morbidity and without compromising the patient's pulmonary function. Further clinical research is necessary to determine its effect on pulmonary metastases in man, especially in case of unresectable disease or as adjuvant therapy after surgical resection.
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Affiliation(s)
- P E Van Schil
- Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
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Schneider P, Foitzik T, Pohlen U, Golder W, Buhr HJ. Temporary unilateral microembolization of the lung-a new approach to regional chemotherapy for pulmonary metastases. J Surg Res 2002; 107:159-66. [PMID: 12429171 DOI: 10.1006/jsre.2002.6511] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Except in patients with resectable disease, treatment of pulmonary metastases is still disappointing. Regional chemotherapy may be a suitable method for delivering more effective doses to regionally confined tumors while minimizing systemic toxicity. We propose an unilateral chemoembolization of the lung applicable by endovascular method. MATERIALS AND METHODS An unilateral microembolization of the lung with degradable starch microspheres (DSM) alone (group 1) and combined with carboplatin (group 2) was performed on Sprague-Dawley rats (n = 12). Microcirculatory parameters were studied by in vivo videomicroscopy and radiological pattern on pulmonary angiogram. RESULTS After injection of DSM, mean embolization time in subpleural capillaries was 7.1 +/- 2.3 min, followed by a mean flow retardation of 14.3 +/- 4.6 min; 21.4 +/- 4.7 min after embolization, original flow of erythrocytes was observed demonstrating reperfusion and reversibility of microembolization. After reperfusion relative fluorescence measured in subpleural alveoli was 0.13 +/- 0.049 in group 1, 0.105 +/- 0.016 in group 2, and 0.11 +/- 0.036 in control group (NS). Alveolar septal diameter was 17.3 +/- 1.13 microm in group 1, 16.8 +/- 1.25 microm in group 2, and 16.6 +/- 1.08 microm in control group (NS), demonstrating neither altered permeability nor pulmonary edema. Pulmonary angiogram confirmed patency of the central pulmonary artery. CONCLUSION For the first time unilateral microembolization of the lung could be established in an experimental model. By injection of DSM, reversible embolization on arteriolar and capillary level could be demonstrated without occlusion of the main branches of the pulmonary arteries. Alveolar-capillary membrane disorder as symptom of early toxicity could not be detected even with additional application of carboplatin.
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Affiliation(s)
- P Schneider
- Department of Surgery, University Hospital Benjamin Franklin, Free University of Berlin, Hindenburgdamm 30, Germany.
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Tsuchiya H, Kanazawa Y, Abdel-Wanis ME, Asada N, Abe S, Isu K, Sugita T, Tomita K. Effect of timing of pulmonary metastases identification on prognosis of patients with osteosarcoma: the Japanese Musculoskeletal Oncology Group study. J Clin Oncol 2002; 20:3470-7. [PMID: 12177108 DOI: 10.1200/jco.2002.11.028] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The prognostic value of the time of identification of lung metastasis was investigated in 280 patients with metastatic lung osteosarcoma as a multi-institutional study of the Japanese Musculoskeletal Oncology Group. PATIENTS AND METHODS The 280 patients with lung metastasis were divided into four groups: group 1, patients with lung metastasis identified at initial presentation; group 2, those with lung metastasis identified during preoperative chemotherapy; group 3, those with lung metastasis identified during postoperative chemotherapy, and group 4, those with lung metastasis identified after completion of treatment. Survivals of the four groups were compared. Additionally, the effects of number of metastatic nodules, metastasectomy, and the effect of chemotherapy on the primary tumor on survival of the four groups were analyzed. RESULTS There were 46 patients in group 1, 30 in group 2, 94 in group 3, and 110 in group 4. The overall 2-year survival rates from the time of identification of lung metastasis were 33%, 31%, 24%, and 40% for groups 1, 2, 3, and 4, respectively, whereas the 5-year survival rates were 18%, 0%, 6%, and 31%, respectively. Patients in group 4 thus demonstrated significantly better prognosis than any of the other patients (P <.0001). CONCLUSION Time of identification of lung metastasis is an important prognostic factor. In terms of clinical behavior, groups 2 and 3 are completely different than group 4. These data ensure the need to stratify stage III osteosarcomas into subgroups according to the time of diagnosis of lung metastases. To improve the survival of osteosarcoma patients, new treatment modalities should be introduced into the treatment armamentarium for lung metastasis from osteosarcoma, especially in groups 1, 2, and 3.
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Affiliation(s)
- Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan.
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Schröder C, Fisher S, Pieck AC, Müller A, Jaehde U, Kirchner H, Haverich A, Macchiarini P. Technique and results of hyperthermic (41 degrees C) isolated lung perfusion with high-doses of cisplatin for the treatment of surgically relapsing or unresectable lung sarcoma metastasis. Eur J Cardiothorac Surg 2002; 22:41-6. [PMID: 12103371 DOI: 10.1016/s1010-7940(02)00216-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE A technique of hyperthermic isolated lung perfusion (ILP) chemotherapy was developed. METHODS Since April 1999, four patients with unilateral (n=2) or bilateral (n=2) sarcoma metastasis confined to a lobe (n=2) or entire lung (n=2) entered into a pilot study of hyperthermic (41 degrees C) ILP with high doses of cisplatin (70 mg/m(2)). Eligibility included drug resistant metastasis and at least four previous surgical metastectomies. The ILP of the lung segments was carried out following metastectomy, for 20-40 min at a rate of 0.3-0.5 l/min, a mean perfusion pressure lower than the own mean pulmonary artery pressure, and an inflow temperature of 41 degrees C or higher. Before and following ILP, the isolated lung segments were flushed with normothermic saline (1 l). Flow was continuously maintained by a centrifugal pump. RESULTS All patients successfully completed 31.7+/-9 min perfusion time at 41.4+/-0.3 degrees C, and this time-point corresponded to the maximal platinum lung-uptake (93.8 ng/mg tissue). The total vascular isolation was confirmed by continuously low systemic cisplatin plasma levels. There was no systemic drug-related toxicity but all patients experienced transient pulmonary toxicity as non-cardiogenic edema of the treated lung segments. With a median follow-up of 12 months, three patients are alive and disease-free and one died from cerebral metastasis without autopsy evidence of local recurrence 13 months following ILP. CONCLUSION Hyperthermic perfusion chemotherapy can be done safely and effectively. It represents a new treatment modality and deserves further investigations for patients with advanced, drug resistant or surgically refractory, lung sarcoma metastasis. However, further studies are needed to limit the ILP-induced pulmonary toxicity.
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Affiliation(s)
- Carsten Schröder
- Division of Cardio-thoracic and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Mürdter TE, Friedel G, Backman JT, McClellan M, Schick M, Gerken M, Bosslet K, Fritz P, Toomes H, Kroemer HK, Sperker B. Dose optimization of a doxorubicin prodrug (HMR 1826) in isolated perfused human lungs: low tumor pH promotes prodrug activation by beta-glucuronidase. J Pharmacol Exp Ther 2002; 301:223-8. [PMID: 11907177 DOI: 10.1124/jpet.301.1.223] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
HMR 1826 (N-[4-beta-Glucuronyl-3-nitrobenzyl-oxycarbonyl]doxorubicin) is a nontoxic glucuronide prodrug from which active doxorubicin is released by beta-glucuronidase. Preclinical studies aimed at dose optimization of HMR 1826, based on intratumoral pharmacokinetics, are important to design clinical studies. Using an isolated perfused human lung model, the uptake of doxorubicin into normal tissue and tumors after perfusion with 133 microg/ml (n = 6), 400 microg/ml (n = 10), and 1200 microg/ml (n = 6) HMR 1826 was compared. Extracellular tissue pH was measured, and enzyme kinetic studies were performed in vitro to investigate the effect of pH on the formation of doxorubicin. Extracellular pH was lower in tumors than in healthy tissue (6.46 +/- 0.35, n = 8 versus 7.30 +/- 0.33, n = 10; p < 0.001). In vitro, beta-glucuronidase activity was 10 times higher at pH 6.0 than at neutral pH. After perfusion with HMR 1826, there was a linear relationship between HMR 1826 concentrations in perfusate and normal lung tissue. After perfusion with 133, 400, and 1200 microg/ml HMR 1826, the final doxorubicin concentrations in normal and tumor tissue were 2.7 +/- 0.9, 11.1 +/- 5.4, and 21.8 +/- 8.4 microg/g (p < 0.05 for all comparisons), and 0.7 +/- 0.3, 8.6 +/- 2.0 microg/g (p < 0.01 versus 133 microg/g), and 8.7 +/- 4.9 microg/g, respectively. This agrees with the enzyme kinetic observations of saturation of beta-glucuronidase at 400 microg/ml HMR 1826 in the acidic environment of the tumor. Therefore, the escalation of the HMR 1826 dose most likely results in higher circulating concentrations than 400 microg/ml but does not increase the uptake of doxorubicin into tumors and, subsequently, antitumor efficacy. The isolated perfused human lung is an excellent model for preclinical investigations aimed at optimization of tissue pharmacokinetics of tumor-selective prodrugs.
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Affiliation(s)
- Thomas E Mürdter
- Dr. Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany.
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Schrump DS, Zhai S, Nguyen DM, Weiser TS, Fisher BA, Terrill RE, Flynn BM, Duray PH, Figg WD. Pharmacokinetics of paclitaxel administered by hyperthermic retrograde isolated lung perfusion techniques. J Thorac Cardiovasc Surg 2002; 123:686-94. [PMID: 11986596 DOI: 10.1067/mtc.2002.120713] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Although paclitaxel is widely used as a systemic agent for the treatment of solid tumors, limited information is available concerning administration of this taxane by regional techniques. The present study was undertaken to evaluate the pharmacokinetics and acute toxicity of paclitaxel administered by hyperthermic retrograde isolated lung perfusion techniques to ascertain its potential for the regional therapy of unresectable pulmonary neoplasms. METHODS Adult sheep underwent 90 minutes of retrograde isolated lung perfusion with escalating doses of paclitaxel and moderate hyperthermia using a protein-free, oxygenated extracorporeal circuit and a steady perfusion pressure of 14 to 16 mm Hg. An additional animal received paclitaxel by means of 1-hour central venous infusion. Paclitaxel concentrations in lung tissues, perfusates, and systemic circulation were determined by high-performance liquid chromotography techniques. Cytotoxicity of paclitaxel in cancer cells and in normal human bronchial epithelial cells was evaluated in vitro using 4, 5-dimethylthiazo-2-yl-25-dipagnyl tetrazolium bromide assays. Lung tissues were examined by hematoxylin-and-eosin techniques. RESULTS Paclitaxel concentrations (maximum concentration and area under the plasma concentration time curve) in perfused tissues increased with escalating perfusate doses. Uptake of drug into lung parenchyma appeared saturable at high paclitaxel exposure; a substantial pharmacokinetic advantage was observed. Paclitaxel concentrations in systemic circulation were undetectable or exceedingly low after perfusion. Histopathologic examination of lung tissues harvested 3 hours after completion of isolated lung perfusion revealed no immediate toxicity, even at a paclitaxel exposure 20-fold higher than that achievable after 1 hour of intravenous administration at the maximum tolerable dose in human subjects. Moderate hyperthermia enhanced paclitaxel-mediated cytotoxicity 5- to 100-fold in cultured cancer lines. No paclitaxel toxicity was observed in cultured normal human bronchial epithelial cells after exposure to paclitaxel under normothermic or hyperthermic conditions. CONCLUSIONS These data support further evaluation of paclitaxel administered by hyperthermic retrograde isolated lung perfusion techniques for the treatment of unresectable malignant pulmonary tumors.
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MESH Headings
- Animals
- Antineoplastic Agents, Phytogenic/administration & dosage
- Antineoplastic Agents, Phytogenic/blood
- Antineoplastic Agents, Phytogenic/pharmacokinetics
- Area Under Curve
- Bronchi/cytology
- Chemotherapy, Cancer, Regional Perfusion
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Epithelial Cells/drug effects
- Humans
- Hyperthermia, Induced/adverse effects
- Infusions, Intravenous
- Lung Neoplasms/blood
- Lung Neoplasms/drug therapy
- Paclitaxel/administration & dosage
- Paclitaxel/blood
- Paclitaxel/pharmacokinetics
- Sheep
- Treatment Outcome
- Tumor Cells, Cultured/drug effects
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Affiliation(s)
- David S Schrump
- Thoracic Oncology Section, Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-1502, USA.
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39
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Müller H. Combined regional and systemic chemotherapy for advanced and inoperable non-small cell lung cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:165-71. [PMID: 11884052 DOI: 10.1053/ejso.2001.1216] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS The objective was to establish the feasibility and toxicity of regional chemotherapy using an isolated thoracic perfusion (ITP) technique plus low dose systemic chemotherapy as induction chemotherapy followed by surgery in advanced non-small cell lung cancer (NSCLC). METHODS twenty-two chemotherapy-naive patients with NSCLC (median age of 57 years, stage III-IV disease with metastases only in the thoracic region, Karnofsky index >60), received two cycles of regional plus systemic chemotherapy with a treatment-free interval of 4 weeks. The cytostatic regimen consisted of 10 mg/m(2) mitomycin, 25 mg/m(2) navelbine and 30 mg/m(2) cisplatin during ITP followed by low-dose systemic chemotherapy with 250 mg/m(2) 5-fluorouracil and 20 mg/m(2) cisplatin given as a continuous infusion on day 1-4. Patients were re-evaluated for response and surgery was carried out if possible. RESULTS All 22 patients could be assessed for toxicity, response and survival. There were 19/22 remissions corresponding to a regression rate of 86.4%; 16/22 patients could be resected. This corresponded to a resectability rate of 72.7% (13 complete resections R0, 1 R1, 2 R2). Side-effects were transient and acceptable with no treatment- or surgery-related deaths. Median survival has not been reached after an observation time of 15 months. The estimated 1-year survival rate was 67.3%. CONCLUSIONS Regional chemotherapy using an ITP application form is highly effective in advanced NSCLC stage III-IV leading to a high rate of resectability with an encouraging survival outcome.
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Affiliation(s)
- H Müller
- Department of Oncologic Surgery, Carl von Hess Hospital, Hammelburg, Germany.
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40
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Abstract
Treatment strategies other than surgery for pulmonary metastases are needed to improve disease-free and overall survival. Surgical attempts to solve a biologic problem by mechanical means. Alternative treatment may include induction or adjuvant chemotherapy, lung perfusion or regional drug delivery, biologic therapies (inhaled IL-2, biologic modifiers), and potentially, molecular or genetic therapy. Experimental radiofrequency ablation techniques are rarely applicable. Combinations of resection of macrometastases with treatment of occult micrometastases may be best in improving disease-free and overall survival.
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Affiliation(s)
- Joe B Putnam
- Department of Thoracic and Cardiovascular Surgery, M.D. Anderson Cancer Institute, 1515 Holcombe Boulevard-Box 445, Houston, TX 77030-4095, USA
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41
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Johnston MR, Mullen JB, Pagura ME, Howard RB. Validation of an orthotopic model of human lung cancer with regional and systemic metastases. Ann Thorac Surg 2001; 71:1120-5. [PMID: 11308147 DOI: 10.1016/s0003-4975(00)02658-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND We developed an orthotopic model of human lung cancer that exhibits highly predictable regional and systemic metastases. This study examines the response of the model when treated with conventional and experimental chemotherapy. METHODS NCI-H460 tumor fragments were implanted into the right caudal lung lobe of a nude rat. Treatment commenced 2 weeks later. We assessed response by comparing primary tumor and mediastinal lymph node weights, total body weight, and length of survival with untreated, tumor-bearing control animals. We also calculated the incidence of metastasis to kidney, bone, brain, and contralateral lung in treated versus untreated animals. RESULTS Mitomycin and cisplatin showed broad activity against primary and metastatic disease. The matrix metalloproteinase inhibitor batimastat, low-dose cisplatin, and mitomycin significantly prolonged survival. High-dose cisplatin caused renal toxicity that shortened survival. Brain metastases did not respond to mitomycin, consistent with its poor blood-brain barrier penetration. CONCLUSIONS Responses were similar to NCI-H460 in vitro data and consistent with clinical experience for these drugs. Drug-related toxicities similar to those seen in clinical practice were detected.
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Affiliation(s)
- M R Johnston
- Division of Thoracic Surgery and the Samuel Lunenfeld Research Institute, Toronto, Canada.
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42
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Sharma S, White D, Imondi AR, Placke ME, Vail DM, Kris MG. Development of inhalational agents for oncologic use. J Clin Oncol 2001; 19:1839-47. [PMID: 11251016 DOI: 10.1200/jco.2001.19.6.1839] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Because regional chemotherapy has been useful in treatment and palliation of many cancer types, the concept of delivering drugs by inhalation for the treatment of cancers in the lung is attractive. Much higher local drug exposure can be achieved with total doses considerably lower than those required for systemic administration, resulting in lower exposure of nonrespiratory tract tissues to potentially toxic drugs. Regional delivery of chemotherapy to the respiratory tract has been shown to have activity in preclinical and clinical studies. Technical improvements in delivery methods have now made it possible to conduct trials of inhalational agents, both to treat cancers affecting the respiratory tract and to deliver other drugs used in cancer patients. This review discusses the rationale of drug delivery by the inhalational route, its technical challenges, preclinical and clinical experiences, limitations, and promise.
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Müller H, Guadagni S. Regional plus systemic chemotherapy: an effective treatment in recurrent non-small cell lung cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2001; 27:190-5. [PMID: 11289757 DOI: 10.1053/ejso.2000.1080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS This study was undertaken to determine the activity and toxicity of regional chemotherapy using an isolated thoracic perfusion (ITP) technique as second-line treatment for patients with advanced and recurrent non-small cell lung cancer (NSCLC). METHODS Eighteen patients with relapsed NSCLC confined to the thoracic region entered the study and received regional chemotherapy using ITP plus low-dose systemic chemotherapy. All 18 patients had been pre-treated with some form of chemotherapy, surgery and/or radiotherapy. The cytostatic regimen had two components: (1) ITP using mitomycin 10 mg/m(2), navelbine 25 mg/m(2)and cisplatin 30 mg/m(2)on day 1; (2) systemic chemotherapy with 5-fluorouracil 250 mg/m(2)and cisplatin 20 mg/m(2)given as a continuous infusion over 24 h on days 1-4. RESULTS All 18 patients were assessable for toxicity, tumour response and survival. There were 10/18 responses (CR 0; PR 10): a response rate of 56%. Side-effects were transient and acceptable. No treatment-related death occurred. Median survival was 21 months and the 1-year survival rate was 75%. CONCLUSIONS Regional chemotherapy using ITP plus low-dose systemic chemotherapy is effective in recurrent advanced NSCLC, with an encouraging survival outcome.
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Affiliation(s)
- H Müller
- Department of Oncologic Surgery, Carl von Hess Hospital, Hammelburg, Germany
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Saeki K, Kaneda Y, Li TS, Ueda K, Esato K. Relationship between the concentration of CDDP in tumor and tumor size after isolated lung perfusion treatment experimental study on a solitary pulmonary sarcoma model in rats. J Surg Oncol 2000; 75:193-6. [PMID: 11088051 DOI: 10.1002/1096-9098(200011)75:3<193::aid-jso7>3.0.co;2-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Few investigations on the pharmacokinetics of isolated lung perfusion (ILP) regional chemotherapy in tumors have been conducted. The purpose of this study was to evaluate the pharmacokinetic character of ILP in tumor tissues. Materials and Methods A solitary tumor nodule model was established in Fisher 344 rats by inoculating 1.0 x 10(6) methylcholanthrene-induced sarcoma cells into the left lung. On 14-21 days after the inoculation of tumor cells, rats were randomized into groups subjected to 10, 20, 40 or 60 min ILP with cis-diamminedichloroplatinum (CDDP) at concentrations of 25, 50, or 100 microg/ml. Total platinum concentration in tumors was measured by a flameless atomic absorption spectrophotometer. RESULTS The average tumor weights and total platinum concentrations were not significantly different among the perfusion groups. We found, however, that the total platinum concentrations in tumor nodules were significantly correlated inversely with the tumor weight (total platinum concentration in tumor = 1.167 x 1/tumor wt; R(2) = 0.981; P < 0.001). CONCLUSIONS The concentration of total platinum in the tumor tissue was found to be dependent on the weight of the tumor in ILP. Higher concentrations of total platinum were expressed in smaller tumor nodules than larger ones, indicating that ILP may be more effective against small tumors than large ones. Therefore, we suggest that large tumor legions should be debulked before ILP in patients with an unresectable lung tumor.
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Affiliation(s)
- K Saeki
- First Department of Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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45
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Ceelen WP, Hesse U, de Hemptinne B, Pattyn P. Hyperthermic intraperitoneal chemoperfusion in the treatment of locally advanced intra-abdominal cancer. Br J Surg 2000; 87:1006-15. [PMID: 10931042 DOI: 10.1046/j.1365-2168.2000.01538.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical treatment of intra-abdominal cancer is often followed by local recurrence. In a subgroup of patients, local recurrence is the sole site of disease, reflecting biologically low-grade malignancy. These patients might, therefore, benefit from local treatment. Recently, debulking surgery followed by hyperthermic chemoperfusion has been proposed in the treatment of locally advanced or recurrent intra-abdominal cancer. This paper reviews the rationale and assesses the currently accepted indications for and results of this novel treatment. METHODS A systematic web-based literature review was performed. Information was also retrieved from handbooks, congress abstracts and ongoing clinical trials. RESULTS A growing body of experimental evidence supports the use of hyperthermia combined with chemotherapy as an adjunct to cytoreductive surgery. Randomized clinical trials are available to support its use in the treatment and prevention of peritoneal carcinomatosis following resection of pathological tumour stage pT3 or pT4 gastric cancer; several other phase III trials are ongoing. Numerous phase I and II trials have reported good results for various other indications, with acceptable morbidity and mortality rates. Case mix, limited patient numbers and absence of a standardized technique are, however, a drawback in many of these series. CONCLUSION For a subgroup of patients with peritoneal cancer without distant disease, debulking surgery followed by hyperthermic chemoperfusion may offer a chance of cure or palliation in this otherwise untreatable condition. This novel therapy should, however, be considered experimental until further results from ongoing phase III trials become available.
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Affiliation(s)
- W P Ceelen
- Department of Abdominal Surgery 2P4, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
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46
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Burt ME, Liu D, Abolhoda A, Ross HM, Kaneda Y, Jara E, Casper ES, Ginsberg RJ, Brennan MF. Isolated lung perfusion for patients with unresectable metastases from sarcoma: a phase I trial. Ann Thorac Surg 2000; 69:1542-9. [PMID: 10881839 DOI: 10.1016/s0003-4975(00)01131-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND In patients with unresectable pulmonary metastases from sarcoma, systemic chemotherapy has had limited efficacy possibly because of dose-limiting toxicities. Isolated lung perfusion is an alternative method of delivering high-dose chemotherapy to the lungs while minimizing systemic toxicities. We present the results of our Phase I trial of isolated lung perfusion with doxorubicin hydrochloride in such a group of patients. METHODS From May 1995 to June 1997, 8 patients with unresectable metastases from sarcoma limited to the lungs underwent isolated lung perfusion with doxorubicin. A dose-escalation schedule starting at 40 mg/m2 was used. Seven patients were treated with a dose of 40 mg/m2 or less, and 1 patient received 80 mg/m2. Blood, tumor, and normal lung samples were obtained at various time points during the operation. Patients were evaluated for cardiac, pulmonary, and other toxicities. RESULTS The doxorubicin concentrations in both normal lung and tumor correlated directly with the amount of doxorubicin in the perfusate. The tumors took up less doxorubicin than the lung. All patients had minimal or undetectable systemic levels of doxorubicin at the conclusion of the perfusion. There were no cardiac or other systemic toxicities. In the 7 patients perfused with 40 mg/m2 or less of doxorubicin, there was a significant decrease in the forced expiratory volume in 1 second and a trend toward a significant decrease in diffusing capacity. The patient who received 80 mg/m2 underwent lung scanning postoperatively, and scans showed no ventilation or perfusion in the perfused lung. There were no perioperative deaths. Two patients are alive with disease, and 6 patients died of disease. The median follow-up is 11 months and the longest, 31 months. There were no partial or complete responses. One patient had stabilization of disease in the perfused lung, whereas the lesions in the untreated lung progressed markedly. CONCLUSION Isolated lung perfusion is well tolerated by patients and effectively delivers high doses of doxorubicin to the lung and tumor tissues while minimizing systemic toxicities. A single dose of 80 mg/m2 resulted in substantial injury to the lung. There were no partial or complete responses in patients perfused with doxorubicin at the maximum tolerated dose of 40 mg/m2. Isolated lung perfusion remains a model for testing new and innovative therapies for metastatic sarcoma.
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Affiliation(s)
- M E Burt
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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47
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Donker R, Stewart DJ, Dahrouge S, Evans WK, Shamji FM, Maziak DE, Tomiak EM. Clinical Characteristics and the Impact of Surgery and Chemotherapy on Survival of Patients With Advanced and Metastatic Bronchioloalveolar Carcinoma: A Retrospective Study. Clin Lung Cancer 2000; 1:211-5; discussion 216. [PMID: 14733647 DOI: 10.3816/clc.2000.n.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We retrospectively analyzed data from the clinical charts of 126 patients with bronchioloalveolar carcinoma (BAC) referred to the Ottawa Regional Cancer Center. The patient group consisted of 49 men (39%) and 77 women (61%). The mean age at diagnosis was 64 years. Most patients were smokers (85%). At diagnosis, 53% were stage Ia-IIIa and 47% were stage IIIb and IV. Forty-one percent of the patients with advanced and metastatic stages (IIIb, IV) underwent surgery. Multifocal disease was present at diagnosis in 41% of the patients, including 6% who had stage IIIb multifocal disease confined to a single lobe. Surgery was associated with prolonged survival in patients with multifocal unilobar or multilobar disease (P = 0.0001). While this apparent benefit of surgery may have been due to selection bias, it supports further exploration of surgery as therapy for multifocal disease. While patients receiving chemotherapy for advanced disease did not survive longer than patients not receiving chemotherapy, chemotherapy was used primarily in patients with more aggressive disease, suggesting that selection bias may have contributed to its apparent lack of benefit. Of the 30 patients treated with chemotherapy, only 3 (10%) achieved an objective response. One third of the patients (34%) developed distant metastases, with a predilection for the brain and bone.
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Affiliation(s)
- R Donker
- Division of Medical Oncology, Ottawa Regional Cancer Centre, Ottawa, Ontario, Canada.
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Li TS, Kaneda Y, Saeki K, Ueda K, Zempo N, Esato K. Pharmacokinetic differences between rat tumour and lung tissues following isolated lung perfusion with cisplatin. Eur J Cancer 1999; 35:1846-50. [PMID: 10674002 DOI: 10.1016/s0959-8049(99)00226-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Isolated lung perfusion has been performed for the treatment of unresectable lung tumours; however, the pharmacokinetics of this procedure remain unclear. This study was conducted to investigate the changes in antitumour drug concentrations in tumour and lung tissues after isolated lung perfusion, using different perfusion times and perfusate drug concentrations. Isolated left lungs were perfused for 20, 40 or 60 min with 25, 50 or 100 micrograms/ml of cisplatin after solitary lung tumour nodules were established in rats, and the total platinum concentrations in the perfused lung and tumour tissues were determined by flameless atomic absorption spectroscopy. The oedema in the perfused lung tissues was evaluated by histological examination and by the wet to dry weight ratios of the lungs. The total platinum concentration increased significantly with perfusion time and increasing perfusate cisplatin concentrations in the lung tissue, but it did not change in the tumour tissue. The wet to dry weight ratios of the lung tissues did not differ significantly among the perfusion groups. Oedema of the perfused lung tissue did not change significantly with the perfusion time or perfusate cisplatin concentration. The results of this study indicate the possibility that different pharmacokinetics exist between tumour and lung tissues following isolated lung perfusion with cisplatin, which could be used as a clinical guide for the selection of appropriate perfusion times and perfusate drug concentrations.
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Affiliation(s)
- T S Li
- First Department of Surgery, Yamaguchi University School of Medicine, Japan
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Roth JA, Beech DJ, Putnam JB, Pollock RE, Patel SR, Fidler IJ, Benjamin RS. Treatment of the patient with lung metastases. Curr Probl Surg 1996; 33:881-952. [PMID: 8909328 DOI: 10.1016/s0011-3840(96)80003-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas, M.D. Anderson Cancer Center, Houston, USA
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50
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Pass HI, Mew DJ, Kranda KC, Temeck BK, Donington JS, Rosenberg SA. Isolated lung perfusion with tumor necrosis factor for pulmonary metastases. Ann Thorac Surg 1996; 61:1609-17. [PMID: 8651757 DOI: 10.1016/0003-4975(96)00166-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A phase I trial was initiated to define the feasibility and safety of single-lung isolation perfusion with tumor necrosis factor-alpha, interferon-gamma, and moderate hyperthermia for patients with unresectable pulmonary metastases. METHODS Twenty patients with lung metastases (Ewing's, 2; sarcoma, 8; melanoma, 6; other, 4) were considered for single-lung isolation perfusion with 0.3 to 6.0 mg of tumor necrosis factor-alpha and 0.2 mg interferon-gamma delivered through an oxygenated pump circuit. Sixteen perfusions were performed in 15 patients (bilateral in 1). Metastases were completely resected (no single-lung isolation perfusion) in 3 patients, 1 patient had extrapulmonary disease, and one single-lung isolation perfusion was aborted for mechanical reasons. RESULTS There were no significant changes in systemic arterial blood pressure or cardiac output during perfusion. Systolic pulmonary artery pressure increased with isolation, but returned to pre-single-lung isolation perfusion levels after clamp release. The maximum systemic tumor necrosis factor-alpha level was 8 ng/mL, whereas pump-circuit levels ranged from 200 to 10,976 ng/mL. There were no deaths, and the mean hospitalization period was 9 days (range, 5 to 34 days). A short-term (6 to 9 month) unilateral decrease in perfused nodules was noted in 3 patients (melanoma in 1, adenoid cystic carcinoma in 1, renal cell carcinoma in 1). CONCLUSIONS Future studies using a combination of biologic modifiers, chemotherapy, and hyperthermia should be pursued to define active cytotoxic agents that will preserve underlying pulmonary function.
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MESH Headings
- Adult
- Blood Pressure
- Carcinoma, Adenoid Cystic/secondary
- Carcinoma, Adenoid Cystic/therapy
- Carcinoma, Renal Cell/secondary
- Carcinoma, Renal Cell/therapy
- Cardiac Output
- Chemotherapy, Cancer, Regional Perfusion
- Feasibility Studies
- Female
- Follow-Up Studies
- Humans
- Hyperthermia, Induced
- Interferon-gamma/therapeutic use
- Lung Neoplasms/secondary
- Lung Neoplasms/surgery
- Lung Neoplasms/therapy
- Male
- Melanoma/secondary
- Melanoma/surgery
- Melanoma/therapy
- Middle Aged
- Oxygenators
- Pulmonary Artery
- Remission Induction
- Safety
- Sarcoma/secondary
- Sarcoma/surgery
- Sarcoma/therapy
- Sarcoma, Ewing/secondary
- Sarcoma, Ewing/surgery
- Sarcoma, Ewing/therapy
- Tumor Necrosis Factor-alpha/administration & dosage
- Tumor Necrosis Factor-alpha/analysis
- Tumor Necrosis Factor-alpha/therapeutic use
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Affiliation(s)
- H I Pass
- Thoracic Oncology Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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